Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Fare diagnosi in adolescenza. Il contributo psicodinamico del PDM-2 e della SWAP-200-A

Essere adolescenti significa affrontare importanti e impreviste trasformazioni a livello fisico, cognitivo, affettivo e relazionale. Tali cambiamenti, e in generale le complessità psicologiche e sociali di questa fase della vita, richiedono, quando è necessaria, una valutazione diagnostica particolarmente articolata. Lo scopo di questo contributo è fornire al clinico una panoramica dell’approccio diagnostico offerto dalla nuova edizione del Manuale Diagnostico Psicodinamico (PDM-2) e dalla versione per adolescenti della Shedler-Westen Assessment Procedure (SWAP-200-A). Oltre a una generale descrizione dei due strumenti, verranno discusse alcune implicazioni cliniche dell’uso del PDM e della SWAP, sottolineando l’utilità di una diagnosi psicodinamicamente orientata per promuovere accurate formulazioni dei casi e trattamenti personalizzati per il paziente adolescente

La relazione terapeutica: quando una relazione diventa veicolo di cambiamento?

Cosa fa di una “relazione” una relazione che cura? La ricerca sul funzionamento e l’efficacia della psicoterapia, in termini sia clinici (effectiveness) sia statistici (efficacy), continua a rappresentare uno dei temi principali della letteratura scientifica. Inizialmente studiata solo in ambito psicoanalitico, negli ultimi anni la relazione terapeutica è stata approfondita anche da altre prospettive teoriche. Alleanza terapeutica, azione terapeutica, relazione reale, transfert, risposte emotive del terapeuta, caratteristiche del paziente, caratteristiche del terapeuta, attaccamento, sistemi motivazionali interpersonali: sono questi alcuni degli ingredienti attivi della situazione clinica. Oggi tutti concordano nell’affermare che la relazione terapeutica è il prodotto dell’incontro tra due soggettività, quella del paziente e quella del terapeuta. La diade terapeutica si ritrova costantemente a co-costruire lo spazio della cura in un’ottica bi-personale. In questo contributo verranno presentati e discussi gli aspetti principali che caratterizzano la relazione terapeutica in una prospettiva d’integrazione tra ricerca empirica e pratica clinica

Personality, mental functioning, and symptoms: assessing suicidal risk with the Psychodynamic Diagnostic Manual, 2nd ed. (PDM-2)

Comprehensive and careful diagnostic assessment is a crucial aspect of the clinical management of suicidal patients. The new edition of the Psychodynamic Diagnostic Manual (PDM-2; Lingiardi &amp; McWilliams, 2017) adds a needed perspective on symptom patterns depicted in existing taxonomies, enabling clinicians to describe and categorize personality patterns, related social and emotional capacities, unique profiles of mental functioning, and subjective experiences of symptoms. This paper provides an overview of the PDM-2, focusing on its diagnostic approach to evaluating patients presenting suicidal intention and behaviors. First, the basic premises of the PDM-2, including its rationale and structure, are briefly discussed. Second, following the multiaxial organization of this diagnostic system, the features and main innovations that can guide clinicians in their assessment and clinical management of suicidal risk are examined

ADOLESCENTS AT HIGH-RISK FOR PSYCHOSIS: EXPLORING THE ROLE OF ATTACHMENT PATTERNS, MENTALIZATION AND CHILDHOOD TRAUMATIC EXPERIENCES

Introduction: Identifying young people at clinical high-risk (CHR) for psychosis provides an important contribution to clinical practice, facilitating the development of intervention strategies aimed to prevent the onset of a full-blown psychotic disorder. Therefore, it is essential to investigate which variables are involved in the development and maintenance of CHR conditions in order to improve the diagnostic understanding and the effectiveness of treatments. Several studies showed high rates of childhood traumatic experiences in CHR individuals. Furthermore, there are pieces of evidence linking attachment adversity to the risk for developing psychosis – involving enduring alterations of specific neurobiological pathways. Previous researches also highlighted the role of mentalization in moderating the risk of transition to psychotic disorders. To date, attachment and mentalization have not been evaluated in CHR patients using interview-based measures. The aim of this study was to explore attachment patterns, mentalization and childhood traumatic experiences among CHR adolescences. Methods: 51 CHR outpatients were compared with 54 other outpatients who did not meet the high-risk criteria. A multi-method diagnostic assessment was implemented, including the Structured Interview for Prodromal Syndromes (SIPS). Adult Attachment Interview was also administered, and the transcripts were further assessed using both the Reflective Functioning (RF) Scale and the Complex Trauma Questionnaire. Results: Although no differences between groups with respect to childhood traumatic experiences have been found, CHR patients showed a higher degree of insecure and disorganized attachment patterns. Moreover, the RF scores were significantly lower in the HR sample and significant correlations between RF and SIPS subscales were found. Conclusions: Our results suggest that attachment-informed and mentalization-based psychotherapies may be effective preventive treatments for CHR patients

Psychodynamic diagnosis in adolescence: how to use PDM-2?

Adolescence is a transitional phase of growth and development characterized by great changes at the physical, cognitive, socio-emotional, and interpersonal level. Because of deep and continuous transformations that this age involves, clinicians are faced with several critical issues in providing a comprehensive and careful diagnostic assessment. Their highest priority when dealing with adolescents’ adjustment problems and psycho(patho)logical experiences is to take into account the labile and fluid nature of adolescents’ mental functioning to avoid the risks of misunderstanding or perhaps even misdiagnosing. The aim of this contribution is to provide an overview of the PDM-2’s innovative approach to diagnosis in adolescence. Overall, the new edition of the Psychodynamic Diagnostic Manual (PDM-2; Lingiardi &amp; McWilliams, 2017) highlights the importance of adapting the diagnostic process to specific developmental stages, and provides a multidimensional and multiaxial approach to describe broadly the adolescent’s overall psychological functioning. The PDM-2’s diagnostic framework proposes an in-depth and systematic assessment of: (1) the profile of the adolescent’s mental capacities, emphasizing their dynamic and mutable nature (MA Axis); (2) the “emerging” personality organization and styles (PA Axis) that represent a meaningful diathesis for psychopathology ; and (3) the subjective experience of symptom patterns (SA Axis). The manual also highlights the critical role of transference and countertransference dimensions relative to distinct clinical syndromes. The implications of the PDM-2’s use for clinical practice will be discussed to clarify the value of a psychodynamically-oriented diagnosis useful for promoting accurate case formulations and planning patient-tailored treatments in adolescence

Attachment Patterns, Mentalization and Childhood Traumatic Experiences in a sample of adolescents at Ultra-High Risk for psychosis

The ultra-high risk (UHR) criteria were defined to identify young people at high and imminent risk of developing the first episode of psychosis. Identifying UHR individuals provides an important contribution to clinical practice, facilitating the development of intervention strategies that can prevent the onset of a full-blown psychotic disorder. Nevertheless, UHR population is highly heterogeneous, displaying varying clinical conditions. This may undermine both clinical research and the assessment and treatment of patients. Therefore, it is essential to investigate which variables are involved in the development and maintenance of prodromal conditions in order to achieve a better diagnostic understanding and to improve the effectiveness of treatments. Several studies showed high rates of childhood traumatic experiences in at risk individuals (Mayo et al., 2017). Furthermore, there are pieces of evidence linking attachment adversity to the risk for developing psychosis (Russo et al., 2017) – an explanation may include enduring alterations of specific neurobiological pathways in children with insecure attachment (Debbané et al., 2016). Previous researches also highlighted the role of mentalization processes in moderating the risk of transition to psychotic disorders (ibidem). To date, attachment and mentalization have not been evaluated in HR patients using interview-based measures. The aim of this study was to explore the quality of attachment patterns, mentalization capacity and childhood traumatic experiences among UHR adolescents outpatients. Methods: 31 UHR adolescent outpatients were compared with 34 other outpatients who did not meet the ultra-high risk criteria. A multi-method/multi-informant diagnostic assessment was implemented, including the Structured Interview for Prodromal Syndromes/Scale for Prodromal Symptoms (SIPS/SOPS). The Adult Attachment Interview (AAI) was also administered, and the AAI transcripts were further assessed using both the Reflective Functioning (RF) Scale and the Complex-Trauma Questionnaire. Results: Although no differences between groups with respect to childhood traumatic experiences have been found, UHR patients showed a higher degree of insecure (χ2[1, N=65]=6.991; p=.008) and disorganized (χ2[1, N=65]=8.242; p=.004) attachment patterns. Moreover, the RF scores were significantly lower in the UHR sample (t=3.369; p&lt;.001) and significant correlations between RF and any SOPS’ subscales were found. Conclusions: Our results underline the importance of taking both insecure/disorganized attachment and mentalization impairments into consideration when planning treatment for psychotic prodromal symptomatology. Our results seem to suggest that attachment-informed and mentalization-based psychotherapies may be effective preventive treatments for UHR patients. Debbané M, Salaminios G, Luyten P, Badoud D, Armando M, Solida Tozzi A et al. (2016). Attachment, Neurobiology, and Mentalizing along the Psychosis Continuum. Frontiers in Human Neuroscience, 10. Mayo D, Corey S, Kelly LH, Yohannes S, Youngquist AL, et al. (2017). The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis: A Review. Frontiers in Psychiatry, 8:55, 1-17. Russo DA, Stochl J, Hodgekins J, Iglesias-González M, Chipps P, Painter M, et al. (2017). Attachment styles and clinical correlates in people at ultra-high risk for psychosis. British Journal Of Psychology, 109(1), 45-62

Poster selected for the "poster blitz"

The ultra-high risk (UHR) criteria were defined to identify young people at high and imminent risk of developing the first episode of psychosis. Identifying UHR individuals provides an important contribution to clinical practice, facilitating the development of intervention strategies that can prevent the onset of a full-blown psychotic disorder. Nevertheless, UHR population is highly heterogeneous, displaying varying clinical conditions. This may undermine both clinical research and the assessment and treatment of patients. Therefore, it is essential to investigate which variables are involved in the development and maintenance of prodromal conditions in order to achieve a better diagnostic understanding and to improve the effectiveness of treatments. Several studies showed high rates of childhood traumatic experiences in at risk individuals (Mayo et al., 2017). Furthermore, there are pieces of evidence linking attachment adversity to the risk for developing psychosis (Russo et al., 2017) – an explanation may include enduring alterations of specific neurobiological pathways in children with insecure attachment (Debbané et al., 2016). Previous researches also highlighted the role of mentalization processes in moderating the risk of transition to psychotic disorders (ibidem). To date, attachment and mentalization have not been evaluated in HR patients using interview-based measures. The aim of this study was to explore the quality of attachment patterns, mentalization capacity and childhood traumatic experiences among UHR adolescents outpatients. Methods: 31 UHR adolescent outpatients were compared with 34 other outpatients who did not meet the ultra-high risk criteria. A multi-method/multi-informant diagnostic assessment was implemented, including the Structured Interview for Prodromal Syndromes/Scale for Prodromal Symptoms (SIPS/SOPS). The Adult Attachment Interview (AAI) was also administered, and the AAI transcripts were further assessed using both the Reflective Functioning (RF) Scale and the Complex-Trauma Questionnaire. Results: Although no differences between groups with respect to childhood traumatic experiences have been found, UHR patients showed a higher degree of insecure (χ2[1, N=65]=6.991; p=.008) and disorganized (χ2[1, N=65]=8.242; p=.004) attachment patterns. Moreover, the RF scores were significantly lower in the UHR sample (t=3.369; p<.001) and significant correlations between RF and any SOPS’ subscales were found. Conclusions: Our results underline the importance of taking both insecure/disorganized attachment and mentalization impairments into consideration when planning treatment for psychotic prodromal symptomatology. Our results seem to suggest that attachment-informed and mentalization-based psychotherapies may be effective preventive treatments for UHR patients. Debbané M, Salaminios G, Luyten P, Badoud D, Armando M, Solida Tozzi A et al. (2016). Attachment, Neurobiology, and Mentalizing along the Psychosis Continuum. Frontiers in Human Neuroscience, 10. Mayo D, Corey S, Kelly LH, Yohannes S, Youngquist AL, et al. (2017). The Role of Trauma and Stressful Life Events among Individuals at Clinical High Risk for Psychosis: A Review. Frontiers in Psychiatry, 8:55, 1-17. Russo DA, Stochl J, Hodgekins J, Iglesias-González M, Chipps P, Painter M, et al. (2017). Attachment styles and clinical correlates in people at ultra-high risk for psychosis. British Journal Of Psychology, 109(1), 45-62

Personality Traits and Disorders in Adolescents at Clinical High Risk for Psychosis: Toward a Clinically Meaningful Diagnosis

Aims: Recent meta-analytic data show that approximately 40% of individuals at clinical high risk for psychosis (CHR) receive at least one personality disorder (PD) diagnosis. Personality pathology could significantly influence CHR patients' prognosis and response to treatment. We aimed at exploring the PD traits of CHR adolescents, in order to outline a prototypic description of their most frequently observed personality characteristics. Methods: One hundred and twenty-three psychiatrists and psychologists used a Q-sort procedure [i.e., the Shedler–Westen Assessment Procedure-200 for Adolescents (SWAP-200-A)] to assess personality traits and disorders in 58 (30 male; mean age = 16 years, range = 13–19 years) CHR adolescents and two gender- and age-matched samples, respectively, with (n = 60) and without PDs (n = 59). Results: Differences between the CHR, PD, and clinical groups showed that CHR adolescents had pervasive and more clinically relevant schizoid, schizotypal, borderline, and avoidant traits, as well as poorer adaptive functioning. Moreover, by collecting the highest mean SWAP-200-A items, we empirically outlined a prototypic description of CHR youths, comprised of avoidance of social relationships; suspiciousness; obsessional thoughts; lack of psychological insight; dysphoric and overwhelming feelings of anxiety and depression; odd and anomalous reasoning processes or perceptual experiences; symptoms of depersonalization and derealization; and negative symptoms of avolition, abulia, blunted affects, and impaired role functioning. Conclusions: The results suggest that avoidant interpersonal strategies, impaired mentalization, and difficulties in emotional regulation could become important targets for psychosocial interventions with CHR adolescent populations